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Pictorial Essay • Radiol Bras 55 (2) • Mar-Apr 2022 • https://doi.org/10.1590/0100-3984.2021.0039 copy

Fractures of the appendicular skeleton and criteria for their surgical management: pictorial essay

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The high prevalence of fractures and the essential role that imaging examinations play in this scenario require the radiologist to be familiar with their main patterns, especially those of fractures for which the management is essentially surgical. This pictorial essay presents a series of illustrative cases and a brief review of the literature, the aim being to demonstrate some of the main fractures of the appendicular skeleton that require surgical management, grouped, didactically, by the joint affected. Radiographic and computed tomography studies of illustrative cases were selected from the imaging archives of our facility.

Keywords:
Fractures, bone/diagnostic imaging; Fractures, bone/surgery; Skeleton/injuries; Bone and bones/injuries; Joints/injuries

Fracture	Segment	Mechanism of trauma	Findings that indicate surgical treatment	Main surgical treatment adopted
Proximal humerus	Proximal humerus	Elderly: falls; young people: high energy traumas	Marked varus or valgus displacement; deviated fracture of the greater or lesser tuberosity; fracture- dislocation; humeral head splitting	Open reduction and internal fixation with a plate and a screw; closed percutaneous reduction and fixation with wires or screws; intramedullary nailing; arthroplasty
Elbow (terrible triad of the elbow)	Radius and proximal ulna	Fall onto an outstretched hand	Loss of congruence of the humeroulnar and humeroradial joints; head fracture with pronation- supination blockage; fracture > 50% of the height of the coronoid process	External fixation; open reduction with internal fixation; ligament repair; radial head excision; radial head arthroplasty
Forearm (Monteggia fracture-dislocation, Galeazzi fracture- dislocation)	Radius and ulna diaphysis	Fall onto an outstretched hand	Monteggia or Galeazzi fracture-dislocations are essentially surgical cases, unless clinical conditions preclude surgery. Signs of injury to the distal radioulnar joint: fracture of the ulnar styloid process; diastasis of the distal radioulnar joint on an anteroposterior X-ray; radial shortening ≥ 5.0 mm; volar or dorsal displacement on a lateral X-ray. Signs of proximal radioulnar joint injury: break in the radiocapitellar line	Open reduction with internal fixation of the fractured bone and assessment of the stability of the joint affected
Distal radius (Barton’s fracture)	Distal radius	Fall onto an outstretched hand	Barton fractures are eminently surgical due to the instability and shear of the fragment. Other injuries: joint depression > 2.0 mm; radial shortening > 3.0 mm; dorsal angulation > 10° or > 20° in relation to the contralateral side. Associated injury (e.g., to a ligament or the ulnar styloid)	Open reduction with internal fixation; external fixation; closed reduction and percutaneous fixation
Scaphoid	Carpus	Fall onto an outstretched hand	Proximal pole fracture: displacement > 1.0 mm; intrascaphoid angle > 35°; comminuted fracture; carpal instability	Percutaneous fixation; open reduction with internal fixation; arthroscopy- assisted reduction and fixation

Fracture	Segment	Mechanism of trauma	Findings that indicate surgical treatment	Main surgical treatment adopted
Pelvic ring (open book)	Pelvis	High energy blunt trauma	Diastasis of the pubic symphysis > 25.0 mm; displacement of the sacroiliac joint; posterior (sacral or sacroiliac) injury, together with anterior injury (fracture of the branches or opening of the pubic symphysis) – except for type 1 lateral shear	External fixation; open reduction with internal fixation
Intertrochanteric	Proximal femur	Elderly: falls; young people: high-energy traumas	Any, except the following: clinical conditions that contraindicate surgery; isolated fracture of the greater or lesser trochanter	Open reduction with internal fixation; closed reduction with internal fixation
Femoral neck	Proximal femur	Elderly: falls; young people: high-energy traumas	Any, although surgery can be conservative if the following are present: fractures without displacement or impacted in valgus (controversial); clinical conditions that contraindicate surgery	Internal fixation; arthroplasty
Tibial plateau	Proximal tibia	Trauma with axial force vector	Joint depression > 2 mm (including depression or shear); change of limb axis (varus or valgus); enlargement of the plateau (condylar diastasis > 5 mm); deviated fractures	Open reduction with internal fixation; external fixation
Ankle	Tibia and distal fibula	Ankle sprain	Loss of joint congruence; malleolar fracture with deviation > 2.0 mm; lateral malleolar fracture with ligament injury: deltoid ligament injury—medial clear space > 4.0 mm; syndesmotic injury—tibiofibular overlap < 10.0 mm in anteroposterior view and < 1.0 mm in true anteroposterior/mortise view; Bimalleolar or trimalleolar fracture	Open reduction with internal fixation
Tarsometatarsal (Lisfranc)	Tarsometatarsal	Motor vehicle accidents, crushes, falls from a height, and sports injury	Deviation > 1.0 mm; joint incongruity > 2.0 mm; instability or diastasis on a weight-bearing X-ray; compartment syndrome; exposed fracture	Open reduction with internal fixation; closed reduction and percutaneous fixation

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E-mail: radiologiabrasileira@cbr.org.br

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